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Supernumerary Teeth in all 4 Quadrants of a Non-
Syndromic Patient with a Positive Family History: A
Case Report

Ezinne Ogbureke*, Stephen Laman, Shawn Adibi and Cleverick D Johnson

Department of General Practice and Dental Public Health, The University of Texas School of Dentistry, Houston, Texas, USA

*Corresponding author: Dr. Ezinne Ogbureke, Department of General Practice and Dental Public Health, The University of Texas School of Dentistry,
Houston, Texas, USA, Tel: 7134864261 E-mail: ezinne.i.ogbureke@uth.tmc.edu

Human growth and development of dentition generally follows
an orderly pattern of an eruption sequence of primary dentition of 20
teeth, followed by an interim time of mixed dentition and concluding
with 32 permanent teeth. The literature is rich with descriptions
of variation of this pattern largely based on addition or deletion
of the genetic code which may include geographic isolation and or
unexplained point mutations. Generally tooth eruption follows,
concluding with the 3rd molar Layman’s terminology “wisdom
tooth” by age 25. The literature describes patients with extra teeth
referred to as supernumerary teeth. Common patient’s diagnosis for
additional teeth includes syndromes such as Cleidocranial dysplasia
or Gardner’s Syndrome. In some patients as with this case report, the
finding doesn’t seem to point out the existence of a syndrome.
This paper highlights a case of 6 supernumerary teeth located
in all 4 quadrants of a patient with a positive family history of
supernumerary teeth, who came in for a routine new patient
screening at The New Patient Diagnostic Clinic” of theUniversity of
Texas School of Dentistry at Houston. His subsequent treatment plan
is discussed as well as a brief review of literature for supernumerary
teeth.Keywords: Multiple supernumerary teeth; Extra teeth;
Hyperdontia; Mesiodens ; Non syndromic

Hyperdontia is defined as the possession of more teeth
beyond the normal complement of dentition and these extra
teeth are referred to as supernumerary teeth [1]. Studies have
shown a higher rate of occurrence in males than females [1-4]
without any conclusive explanation to the reason in this gender
preference. The incidence in primary dentition is less than in
the permanent dentition and ranges between 0.3% and 0.8%,
and in permanent dentition, between 0.1% and 3.8% according
to the population studied [2,4]. Supernumerary conditions can
occur in any location, but they have a predilection for the maxilla
[1-4] and approximately 76-86% of cases occur as single tooth
supernumerary [5]. In a study of 152 child cases in a Jordanian
population, 90% of the supernumerary teeth where found in the premaxilla area and while 77% of the subjects had just one
supernumerary, 18.4% had two and 4.6% had three or more
[2]. Mesiodens, defined as a supernumerary tooth located
predominately in the premaxilla area between the two upper
centrals are the most commonly encountered supernumerary
tooth in children occurring in 0.15% to 1.9% of population
[1,4,6]. These extra teeth could be fully formed and resembling
the tooth adjacent to its location or rudimentary, the commonest
shape being conical. They could be erupted, partially erupted
or impacted. The commonest location of these teeth is the
upper anterior central area followed by the upper premolar
area in studies. While these teeth commonly are located in the
tooth bearing area when they occur, there are documentations
of ectopic locations such as the paranasal sinuses or the nasal
cavity. Multiple supernumerary teeth on a non syndromic patient
is a rare phenomenon, a search on an online repository produced
only 18 results and of the 18 cases only 3 by Batra et al. [7], Babu
et al. [8] and Desai and Shah [9] had associated family history
of similar occurrence thereby making this an interesting topic
for further genetic analysis. Supernumeraries can be classified
by their position as mesiodens, paramolars, distomolars or
parapremolars [10]. They maybe single, multiple, unilateral,
bilateral, erupted or unerupted and can affect upper or lower
jaws [11]. They can also be described based on their form [3] as
Conical - The commonest presentation, seen in 69.6% of
cases and as the name implies, shaped like a cone with fully
formed roots [3].Tuberculate - These are barrel shaped, with incomplete
roots and usually impacted while preventing eruption of other
teeth. Found in 17.7% of cases [12].Supplemental - These resemble adjacent teeth and occurs in
about 11.3% of cases [12].Compound and Complex Odontomas - Multiple
supernumerary teeth are uncommon without associated
syndromes and the commonest syndromes associated with
supernumerary teeth are Gardner’s syndrome (up to 20%
may express clinical signs such as supernumerary teeth), Cleidocranial dysplasia as well as cleft lip palate [1,2,5,11]. Other
rarer syndromes with associated hyperdontia include Ehler
Danlos, Fabry-Anderson and Crouzon’s syndrome.
It is important to rule out associated syndromes for many
supernumerary conditions because the morbidity and sometimes
fatal implications may warrant medical care, genetic counseling
for the patients and their families.

A 35 year old male presented to the Diagnostic clinic
at University of Texas School of Dentistry (UTSD) wanting
to be a patient of the school. Using the American Society of
Anesthesiologists classification, patient was determined to be
ASA 1 (Healthy patient with no systemic diseases). Extra oral
and head and neck examinations revealed no abnormalities.
Intraorally, the patient had no obvious soft tissue pathology and
dental hard tissue examination revealed the presence of several
supernumerary teeth amongst other findings. On the upper right
quadrant, there is a fully erupted supernumerary buccal of #2
and another palatal of #5. On the upper left quadrant there is
an impacted microdont between #12 and 13 while on the lower
left quadrant features a lingually placed supplemental premolar
between #20 and 21 and the lower right had two extra premolars
Figures: 1,2,3,4. A total of 6 supernumeraries with 5 erupted
and 1 impacted. Patient’s family history from questioning was

Figure 1:

Panoramic radiograph showing supernumerary teeth in premolar
areas of lower left and right quadrants.

Figure 2:

Periapical radiographs showing supernumerary teeth adjacent
to #5 on the upper right, an impacted tooth adjacent to #12 on the
upper left and in the lower premolar areas.

Figure 3:

Showing two extra premolars lingual of the lower right premolar
area and one in the same location on the lower left quadrant.

Figure 4:

Showing rudimentary supernumerary palatal of the upper
right premolars .

positive for supernumerary teeth. He reported that his mother
and two sisters had at least three extra teeth each. The patient
has a 3 unit bridge replacing #8 (upper right central incisor)
and a dental history reveals he had a tooth extracted in the area.
It is important to highlight that patient was of normal stature
with no facial or clavicular features of cleidocranial dysplasias
like frontal and parietal bossing, hypertelorism, hypoplastic
clavicles. His panoramic radiographs had no multiple impactions
of cleidocranial dysplasias and Gardner’s neither were there
any jaw radiopacities indicative of presence of jaw osteomas, a
diagnostic feature of Gardner’s syndrome [13].

The precise etiology of supernumeraries is not known
and different theories abound as to their possible origin [12].
The theory of atavism which postulates that supernumeraries
represent a relic of extinct ancestors with more compliment of
teeth than exists today is no longer popular and a second theory of
dichotomy says that a tooth bud divides to form a supernumerary
[2,12]. Heredity is also thought to play a role in development of
supernumeraries [2]. However, the most widely supported view
is that they arise from proliferation of the dental lamina [12,14].
Studies show a higher male to female ratio [1-4] and our patient
is a male. Most supernumerary teeth, as much as 75-95% are
impacted [1,2,14] but in this patient, out of the 6 supernumerary
teeth present, five are erupted with one impacted. While the
premaxila area is the commonest location for supernumeraries,
the premolar is considered to be the second commonest [3]. Yusof
[15] in a systemic literature review also identified the premolar region as the commonest region for multiple supernumerary
teeth in non-syndromic patients coinciding with our findings in
this patient where 5 of the 6 supernumerary teeth were located
in the premolar region of all four quadrants. Patient had a history
of a ‘small tooth’ being extracted in his upper anterior area and
the authors suspect it could have been a mesiodens. It was not
clearly stated how and if #8 (upper right central incisor) was lost.
Based on description, the three supernumeraries on the lower
right and left quadrants as well the one buccal of #2 (not clearly
pictured) could be described as supplemental para premolars
and paramolar while that situated palatally on the upper right
quadrant could be described as conical in Figures: 3 and 4.

Treatment planning for a patient with multiple supernumerary
teeth can be challenging due to the extent and possible severity
of inherent malocclusion requiring a multidisciplinary approach
for treatment. In this case caries risk, partial impactions of
mandibular third molars and irregularly conical shaped form
of clinical crowns have added another wrinkle to the planning
of the treatment. In some cases, if patient desires, orthodontic
considerations may be needed to correct occlusion and achieve
a more functional and esthetic outcome where possible. The
treatment plan for this patient is a multi-disciplinary approach
and includes operative procedures for caries, extraction of all
four 3rd molars and the grossly carious #28, an orthodontic
consult for possible movement of one of the supplementals into
the space for #28 and extraction of the remaining supernumerary
except the impacted microdont on the upper left side which is
asymptomatic at this time but should it become symptomatic
subsequently, it would have to be surgically removed.
Consequences of supernumerary teeth include malocclusion,
impactions, retained primary dentition and cyst formation [12].
There have also been documented cases of ectopic supernumerary
teeth in the maxillary sinus and nasal cavity with associated
symptoms of nasal discharge, epistaxis, headaches, facial pain,
numbness and hemoptysis [7,16-18]. It is not uncommon for
the patients to have a high caries rate due to the crowding and
subsequent difficulty in maintaining good hygiene. Impacted
supernumeraries could also cause root resorption on adjacent
tooth while some may delay or prevent eruptions of permanent
teeth [7,19] prompting their surgical removal.
In this patient, the presence of supernumerary teeth on the
lower right quadrant seemed somewhat a blessing as the extra
tooth could be orthodontically moved into the space to replace
#28 after its extraction.
The absence of sebaceous cysts, multiple jaw osteomas,
odontomas and multiple impactions on the panoramic
radiograph eliminates the possibility of Gardner’s syndrome.
Patient was of normal height , showed no clavicular hypoplasia,
frontal and parietal bossing, hypertelorism or depressed nasal
bridge, hypodontia, multiple impactions and other features
characteristic of Cleidocranial dysplasia. The presence of a
positive family history of supernumeraries in this case patient
however, opens up an avenue for a possible further investigation. Multiple supernumeraries in a non syndromic patient is rare.
A search of International literature on an online repository for
“multiple supernumerary teeth on a non syndromic patient”
yielded 18 results out of which only 3 of the reported cases had a
positive family history. In one of these three cases as documented
by Batra et al. [7], family history of multiple supernumeraries has
been reported as inheritable in an autosomal dominant fashion.

Clinical cases of patients with supernumerary teeth should
prompt inquiry into the possibility of correlated genetic
syndrome. Furthermore, this should trigger other workup
procedures such as additional imaging/X-ray investigations into
the possibility of other related extra bony conditions. Where
genetic correlate is identified, there may be the necessity to
involve genetic counselors in the management of these patients.